Qmentum Program. Diagnostic Imaging Services STANDARDS. For Surveys Starting After: January 01, Accredited by ISQua

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1 STANDARDS Diagnostic Imaging Services For Surveys Starting After: January 01, 2014 Date Generated: August 27, 2014 Ver. 9 Accredited by ISQua

2 Published by Accreditation Canada. All rights reserved. No part of this publication may be reproduced, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without proper written permission from Accreditation Canada. Ver. 9 Diagnostic Imaging Services

3 Accreditation Canada would appreciate your feedback on these standards Your Name: Organization Name: address or telephone number where an Accreditation Canada Product Development Specialist may contact you about your feedback: Feedback: Please indicate the name of the standard, as well as the criterion number in your comments. Please be as specific as possible in your comments. For example: I would like to provide comments on the Long-Term Care Services standards, criterion Clients should be included in this process. I suggest you change the wording to "The team engages staff, service providers, and clients in the process to plan services." You may also submit your feedback online at: [YOUR COMMENTS HERE] Thank you for your input! Please send this page to: Program Development Accreditation Canada 1150 Cyrville Road Ottawa, ON K1J 7S9 Fax: ProgramDevelopment@accreditation.ca

4 Introduction Diagnostic imaging services assist medical professionals in diagnosing, monitoring and treating their clients health conditions. Referring medical professionals work with diagnostic imaging providers to select the most appropriate and least invasive diagnostic imaging examination that can achieve the desired results. Diagnostic examinations may include radiology, magnetic resonance imaging, computed tomography, interventional radiology, bone densitometry, ultrasound, mammography, and nuclear medicine (including positive emission tomography). Accreditation Canada s Diagnostic Imaging Services Standards are for organizations providing diagnostic imaging services in a hospital or as an independent centre. These standards promote an integrated approach to diagnostic imaging services where diagnostic imaging providers work with referring medical professionals to deliver safe and quality diagnostic imaging services to clients. Accreditation Canada s Diagnostic Imaging Services Standards contain the following sections: Meeting the needs of clients and referring medical professionals Having the right people Providing a suitable environment Selecting, operating and maintaining diagnostic imaging equipment Providing safe and appropriate diagnostic imaging services Keeping records accurate, up-to-date and secure Monitoring the safety and quality of diagnostic imaging services Glossary Ver. 9 1 Diagnostic Imaging Services

5 Client: A person receiving diagnostic imaging services. Diagnostic imaging provider: Physicians and technologists providing diagnostic imaging services within the organization. Emergent request: Emergent care refers to a medical situation where care is required immediately. For example, a spinal cord injury may lead to an emergent request for diagnostic imaging services. Organization: Hospital or independent clinic providing diagnostic imaging services. Referring medical professionals: Service providers referring clients to diagnostic imaging services (e.g. physicians, nurse practitioners, dentists, chiropractors, podiatrists, and registered midwives). Team: Depending on services provided, the team may include clinical and administrative leaders, diagnostic imaging providers (i.e. physicians and technologists), anesthesiologists, biomedical engineers, physicists, and administrative staff. Urgent request: Urgent care refers to a medical situation where the condition is unlikely deteriorate or result in death if not addressed immediately but is indicated to be done in a timely manner. For example, a suspicion of cancer may lead to an urgent request for diagnostic imaging services. 2

6 Diagnostic Imaging Services MEETING THE NEEDS OF CLIENTS AND REFERRING MEDICAL PROFESSIONALS 1.0 The team plans and designs its diagnostic imaging services to meet the needs of current and future clients and referring medical professionals. 1.1 The team collects information at least annually about service volumes, wait times, client perspectives on services, and trends in service needs across different groups such as age or condition-specific populations. Collecting this information helps the team evaluate the demand for services, identify patterns in service needs, and determine the resources needed. 1.2 The team collects information at least annually from referring medical professionals about their needs for diagnostic imaging services. Referring medical professionals may include physicians, nurse practitioners, dentists, chiropractors, podiatrists, and registered midwives. The team may collect this information by administering questionnaires or conducting interviews with referring medical professionals. Results are shared with referring medical professionals. Client-centred Services 1.3 The team meets at least annually to review information collected from clients and medical professionals to identify strengths and areas for improvement in service needs, and make changes accordingly. 1.4 The team establishes partnerships to provide coordinated diagnostic imaging services. Continuity of Services 3

7 Partners may include referring medical professionals and other organizations providing diagnostic imaging services. For independent diagnostic imaging centres, partners may also include hospitals. 1.5 The organization sets clear lines of accountability for diagnostic imaging services delivered across the organization. In hospitals, diagnostic imaging services may be provided in other service areas than the imaging department. For example, cardiologists may perform cardiac ultrasound examinations within the cardiology department. In these cases, the organization defines who is responsible to ensure that policies and procedures for diagnostic imaging services are consistently applied across the organization (e.g. staff qualifications, radiation protection, and operation and maintenance of equipment). 2.0 The team provides timely access to diagnostic imaging services. 2.1 The team tracks wait times and average response times for elective, urgent and emergent requests for diagnostic imaging services. Accessibility 2.2 The team identifies, and removes where possible, physical and systemic barriers that prevent clients or referring medical professionals from accessing diagnostic imaging services. Access may be compromised by barriers that are under the team's control (e.g. hours of operation, physical or language barriers) or by barriers that are not (e.g. transportation, long wait times). 2.3 The team regularly seeks input from referring medical professionals about how to improve access to diagnostic imaging services and address delays in reporting diagnostic imaging results. 4

8 The organization defines what regularly means and adheres to that schedule. Input from referring medical professionals is reviewed as needed, and particularly in the event of excessive delays in service. 2.4 The team identifies the resources needed to deliver efficient and timely diagnostic imaging services. Efficiency Resources may be financial, informational, structural or related to equipment. The availability of resources may depend on the continuity of funding as well as opportunities to share resources with other organizations. Team leaders advocate on the team's behalf for the resources needed to achieve the team's goals and objectives. 5

9 HAVING THE RIGHT PEOPLE 3.0 The diagnostic imaging providers are trained, qualified and competent. 3.1 The team has position profiles that define qualifications, roles and responsibilities. Worklife Position profiles include a position summary, specify qualifications and minimum requirements for the position, state the nature and responsibilities of the position, and clarify reporting relationships. 3.2 The team recruits and selects team members based on their qualifications, experience, and fit within the team. Worklife 3.3 The team has a management structure in place with clear reporting relationships and lines of accountability. 3.4 The team has an administrative leader responsible for the administration and management of diagnostic imaging services including supervising and directing diagnostic imaging providers. 3.5 The team has a medical director responsible for supervising and directing physicians. 6

10 3.6 The team's medical director and physicians are imaging specialists credentialed by the appropriate professional college or association. Certification requirements vary by jurisdiction. Medical directors are normally certified by the Royal College of Physicians and Surgeons of Canada and their respective provincial college of physicians and surgeons, or by the Collège des médecins du Québec. 3.7 The team's diagnostic imaging providers delivering specialized modalities have specific credentials or training and are approved by their respective college or association to practice each specialized modality. Specialized modalities may include echocardiography, magnetic resonance imaging, nuclear medicine, position emission tomography, radiography, computed tomography, mammography and ultrasound. 3.8 Team members who administer sedation or monitor clients under sedation maintain a current certificate of proficiency in basic cardiopulmonary resuscitation (CPR). 3.9 The team supports diagnostic imaging providers to participate in professional development activities on a regular basis. The organization defines what regular means and adheres to that schedule. Professional development activities are related to the team's clinical activities (e.g. equipment training). Support may include access to e-learning programs, time off for coursework or conferences, and tuition reimbursement. 7

11 3.10 The team evaluates and documents each team member's performance in an objective, interactive, and constructive way. Worklife The team follows the established process to evaluate each team member's performance. When evaluating performance, the team reviews the individual's ability to carry out responsibilities and consider the individual's strengths, areas for improvement, and contributions regarding client safety and other areas described in the position profile. They may also seek client or peer input. A performance evaluation is usually done before the probationary program is completed, and annually thereafter or as defined by the organization. An evaluation may also be completed following periods of retraining, e.g. when new equipment, or skills are introduced Each team member has an up-to-date, comprehensive personnel file or employment record. Worklife Personnel files may include the employment contract, record of credentials, training information and performance review documentation. 8

12 PROVIDING A SUITABLE ENVIRONMENT 4.0 The team works in a safe, clean, and private physical environment. 4.1 The physical environment has clear signage in place to direct clients to the imaging service. Efficiency 4.2 The team has a separate service area that includes space for clients to wait and space for conducting diagnostic imaging procedures. Client-centred Services 4.3 For nuclear medicine, the team designates separate waiting areas to segregate clients who have been injected with radioactive substances from other clients. 4.4 The client service area includes a space for screening clients which respects confidentiality issues prior to their diagnostic imaging examination. Client-centred Services 4.5 The client service area is equipped with a private and secure space for clients to change. Client-centred Services 9

13 The team protects the client's belongings from theft or loss by offering a secure area for their storage and restricting access to the unit or service area. 4.6 The client service area includes client washrooms. Client-centred Services 4.7 The client service area includes a space with appropriate equipment and staff for clients to recover following the examination. This space is used to ensure clients receiving medications such as sedatives are stable and can be released. 4.8 The client service area is accessible to clients using mobility equipment such as wheelchairs, walkers and crutches. An accessible environment includes washrooms accessible to clients with limited mobility, doorways sufficiently wide to allow access for clients in wheelchairs, and at least one changing area large enough to accommodate a caregiver to help the client. 4.9 The team knows how to identify and report any environmental issues with the temperature, humidity, and ventilation. Maintaining proper temperature, humidity, and ventilation ensures client and staff safety, as well as optimum equipment function. 10

14 4.10 The team posts safety warnings at the entrance of the imaging room and restricts access when it is in use. warnings may include warning labels about radiation and hazards such as the presence of magnetic fields for magnetic resonance imaging procedures The team has a back-up electrical power system that's regularly tested and meets applicable regulations. The organization defines what regularly means and adheres to that schedule. 5.0 The team follows policies and procedures for the safe storage, handling, and disposal of materials and supplies. 5.1 The team is oriented and updated on the Workplace Hazardous Materials Information System (WHMIS) regulations. 5.2 The team labels and stores chemicals and solutions in compliance with WHMIS regulations. 5.3 The team stores, handles, and disposes of radioactive material in compliance with the Canadian Nuclear Commission. For information on the laws and regulations set by the Canadian Nuclear Commission, refer to 11

15 5.4 The team cleans up and disposes of contaminated materials from spills, blood, and bodily fluids in compliance with WHMIS regulations. For materials not included in WHMIS, the team follows the organization's policy for managing hazardous materials. 5.5 The team discards glassware, sharps, and needles in puncture-resistant containers prior to disposal. 12

16 SELECTING, OPERATING, AND MAINTAINING DIAGNOSTIC IMAGING EQUIPMENT 6.0 The team follows policies and procedures for selecting and operating diagnostic imaging equipment. 6.1 Diagnostic imaging providers participate in the organization's process for selecting and prioritizing diagnostic imaging equipment and devices. Other stakeholders involved in the equipment selection process may include biomedical engineers, infection control practitioners and information technologists. 6.2 The team follows provincial and federal regulations to register, install, and calibrate diagnostic imaging equipment. For more information, refer to Health Canada Code 20A (1999): X-Ray Equipment in Medical Diagnosis Part A: Recommended Procedures for Installation and Use and Code 35: Procedures for the Installation, Use and Control of X-ray Equipment in Large Medical Radiological Facilities (2008). Appendix V includes a list of Federal/Provincial/Territorial Radiation Agencies. 6.3 Diagnostic imaging providers have an up-to-date manual for operating diagnostic imaging equipment that includes manufacturer's instructions and applicable safety regulations. The manual includes information from the manufacturer regarding any special safety precautions. 6.4 Diagnostic imaging providers are trained on the diagnostic imaging equipment used by the team prior to use. Training is provided by appropriate personnel (e.g. equipment manufacturer) on new equipment and following upgrades and/or updates to existing equipment. 13

17 6.5 Diagnostic imaging providers have a Policy and Procedure Manual that includes detailed procedures for positioning the client for diagnostic imaging examinations that is signed by the medical director or designate. The manual includes instructions on how to prepare clients for the procedure, perform each step of the procedure, type and dose of medication required (if applicable), and care for the client after the procedure. Designate refers to the physician in charge of the service. 6.6 The team orients new diagnostic imaging providers to the Policy and Procedure Manual. 6.7 The team annually reviews and updates the Policy and Procedure Manual. 6.8 The team informs the diagnostic imaging providers of updates to the Policy and Procedure Manual, and when new procedures are developed. 6.9 The team retains previous versions of the Policy and Procedure Manual according to the organization's policy on record retention. The organization's policy on record retention should be in line with applicable regulations. 14

18 7.0 The team follows policies and procedures for maintaining all diagnostic equipment used by the organization. 7.1 The team has an annual program for preventive maintenance of equipment consistent with manufacturers' recommendations. 7.2 The team has an equipment log in which to record maintenance and downtime, and to identify and address problems. 7.3 The team retains preventive maintenance records for at least two years. 8.0 The team follows a schedule for cleaning and reprocessing all diagnostic devices and equipment. 8.1 The individual responsible for the overall coordination of reprocessing and sterilization activities within the organization reviews and approves the team's set up and policies and procedures for cleaning and reprocessing. 8.2 If the team does not have access to the resources needed to safely clean and reprocess diagnostic devices or equipment at the point of use, the team sends them to the medical device reprocessing department or an external provider. 15

19 Examples of diagnostic devices include ultrasound probes (e.g. transesophageal and transrectal). External providers include organizations with a centralized reprocessing area or private organizations specializing in reprocessing and sterilization services. Additional information can be found in CSA Standards Z and Z , Clause If cleaning and reprocessing are contracted to external providers, the organization establishes and maintains a contract with each provider and monitors the quality of services provided. The organization establishes and monitors minimum requirements for its contracted services and verifies that each external provider follows accepted standards of practice, e.g. CSA Standards. External providers engage in quality monitoring activities, e.g. daily monitoring of printouts and data, maintain reporting systems and data collection, and provide mechanisms to report deficiencies such as defective wraps or items that arrive soiled. The organization reviews copies of reports and printouts and any other documentation demonstrating the quality monitoring performed by the external provider. 8.4 The team follows the organization's policies and procedures and manufacturers' instructions to contain and transport contaminated devices and equipment to the medical device reprocessing department or external provider. 8.5 The team ensures the staff involved in cleaning and reprocessing diagnostic devices and equipment are qualified and competent. Worklife Contaminated probes are a potential source of infection for clients, staff, and service providers. The organization has written requirements for qualification and competency; verifying the qualifications and competency of staff involved in the reprocessing of diagnostic devices is important in preventing the mishandling or improper reprocessing of these devices. 8.6 All diagnostic imaging reprocessing areas are physically separate from client service areas. 16

20 Work areas are cleaned daily. 8.7 All diagnostic imaging reprocessing areas are equipped with separate clean and decontamination work areas as well as separate clean storage, dedicated plumbing and drains, and proper air ventilation and humidity levels. Ventilation helps to remove toxic chemical vapors from the work areas and may include special equipment such as fume hoods. The organization regularly monitors air quality according to its policies and procedures, and Occupational Health & (OHS) legislation. Storage areas are also well-ventilated and cleaned and disinfected at least weekly. 8.8 The team follows the organization's policies and procedures and manufacturer's instructions to select appropriate cleaning, disinfecting, and reprocessing methods. The team refers to the organization's infection prevention and control policies and procedures regarding the selection and testing of disinfectants. These policies and procedures should be in line with a recognized classification system (e.g. Spaulding's) to identify critical, semi-critical, and non-critical items based on the risk of infection. Each classification has requirements for reprocessing that reduce the risk of infection. 8.9 The team follows the organization's policies and procedures and manufacturer's instructions for cleaning and reprocessing diagnostic devices and equipment. The team refers to the organization's overall policies and procedures for disinfection that cover sorting, soaking, washing, rinsing and drying the items, as well as inspecting each item after drying to ensure proper functioning and to identify any chips, inappropriate sharp edges, wear, and other defects. Any damaged medical device is removed from service and documented. For more information, refer to CSA Standards Z , Z and Z The team stores clean diagnostic devices and equipment according to manufacturer's instructions and separate from soiled equipment and waste. 17

21 To minimize damage to diagnostic imaging probes, the team avoids storing them coiled or in their cases. Probes with channels are stored vertically, with channel valves outside the probe The team has a process to track all reprocessed diagnostic devices and equipment so they can be identified in the event of a breakdown or failure in the reprocessing system. Tracking of diagnostic imaging devices and equipment is carried out whether or not the organization has a medical device reprocessing department. The information must be readily available and shared with the medical device reprocessing department where applicable The individual responsible for the overall coordination of reprocessing and sterilization activities within the organization oversees the team's compliance with the organization's policies and procedures on cleaning and reprocessing. 18

22 PROVIDING SAFE AND APPROPRIATE DIAGNOSTIC IMAGING SERVICES 9.0 The team manages and responds to requests for diagnostic imaging services. 9.1 The team has a process for providing referring medical professionals with resources for selecting appropriate diagnostic imaging examinations. For example, the Canadian Association of Radiologists (CAR) developed the CAR Diagnostic Imaging Referral to guide referring medical professionals in their selection of diagnostic imaging examinations. Accessibility 9.2 For diagnostic imaging services, the team receives a written or electronic request that identifies the client and appropriate medical professionals, date of request, level of urgency, relevant clinical information, type of procedure, and special instructions. Basic client identifiers include the client's name, identification number, age or date of birth, gender and contact information. Appropriate medical professionals include referring medical professionals and any other medical professionals who are to receive a copy of the report. Contact information for these medical professionals is also included in the request. Clinical information includes indications, history (e.g. known allergies), provisional diagnosis, and whether a stat report is required. 9.3 If an urgent or emergent request for diagnostic imaging services is made by telephone, a qualified team member collects and records information and ensures a written or electronic request is received prior to interpreting the results of the diagnostic imaging examination. The team records information such as the procedure(s) requested, working diagnosis, name of referring medical professional, and date and time of request. 9.4 If information on a diagnostic imaging services request is incomplete, the team collects additional information prior to conducting the procedure. 19

23 The team may contact the referring medical professional or interview the client to obtain the necessary information. 9.5 The team maintains a written or electronic record of requests for diagnostic imaging services received from referring medical professionals. 9.6 The written or electronic record shows the daily requests for examinations and includes each client's name, examination type, and the image file number. 9.7 The team responds to stat orders within a timely manner. The organization defines what timely means and adheres to that schedule The team prepares clients and their families for diagnostic imaging examinations The team respects the client's diversity including gender, culture, language, religion, and disability when providing diagnostic imaging services. Client-centred Services For example, the team respects the client's choice to have a diagnostic imaging provider from the same gender complete the examination. 20

24 10.2 The team provides clients and their families with information on diagnostic imaging examinations. Client-centred Services Information includes how to prepare for the procedure and addresses concerns such as radiation exposure, appropriate imaging studies, and clinical efficacy. Client-centred Services 10.3 The team reviews information about the diagnostic imaging examination with clients and their families and obtains informed consent either verbally or in writing before conducting the procedure. This information includes why the examination was chosen, what are the benefits, risks and alternatives (if applicable), and what diagnostic information can be expected from it. This information can be provided to clients by the referring medical professional. However, the team reviews this information with the client as part of the process for obtaining informed consent. Client-centred Services 10.4 The team understands their roles and responsibilities when clients are unable to make informed decisions, and involves a substitute decision maker when appropriate. A substitute decision maker may be specified in legislation and may be an advocate, family member, legal guardian, or caregiver. If consent is given by a substitute decision maker, the name of the substitute decision maker, the relationship to the client, and the decision made is recorded in the client record The team screens clients for allergies and medical conditions prior to the administration of contrast media. For example, the team screens client for history of renal disease. The referring medical professional can complete this screening. However, the team reviews any pertinent clinical information that may have an impact on the diagnostic examination. 21

25 10.6 For procedures involving radiation to the abdomen or pelvis on women, the team asks female clients of childbearing age whether they are or may be pregnant and documents the response. There is a protocol for managing clients who are or maybe pregnant The team screens clients for implants, devices, and materials inside the body. The team obtains information and documentation about the risks associated with implants, devices, and materials that may hinder the safety of the client and staff as well as the quality of the diagnostic image The team conducts diagnostic imaging examinations. Client-centred Services 11.1 The team, in consultation with the referring medical professional, chooses the least invasive diagnostic imaging technique necessary to achieve the desired results The team shields clients and diagnostic imaging providers during diagnostic imaging examinations in line with Health Canada regulations and, if applicable, the Canadian Nuclear Commission. For more information, refer to Health Canada Code 35, Sections 2 and 3 on Procedures for Minimizing Radiation Exposure to Personnel and Patients (2008), and to the Radiation Protection Regulations issued by the Canadian Nuclear Commission (2000) for nuclear medicine studies. Procedures include providing clients with gonadal shields as appropriate. Diagnostic imaging providers are also required to wear individual thermoluminescent radiation devices that are monitored and reviewed by a qualified individual. Dosimeters are used to measure and monitor levels of radiation received by clients and diagnostic imaging providers. Magnet-safe headphones or earplugs are readily available to protect against temporary or permanent hearing loss as a result of vibrations produced during magnetic resonance imaging examinations. 22

26 11.3 The team follows a specific procedure for people who assist in diagnostic imaging examinations. For example, the team may need to provide the individual assisting the client with personal protective equipment. Clients with limited mobility may be assisted by a caregiver REQUIRED ORGANIZATIONAL PRACTICE: The team uses at least two client identifiers before providing any service or procedure. Failure to correctly identify clients may result in a range of adverse events such as medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families. Client misidentification was identified in more than 100 individual root cause analyses by the US Department of Veterans Affairs National Center for Patient from January 2000 to March The UK National Patient Agency reported 236 incidents and near misses related to missing wristbands or wristbands with incorrect information between 2003 and Evidence has shown decreases in client identification errors when revised client identification systems are used. The team uses means of identification that are appropriate to the type of services provided and population served. The information obtained needs to be specific to the client, and examples include person-specific identification number such as a registration number; client identification cards such as the health card with name, address, date of birth; client barcodes; double witnessing; or a client wristband. Two client identifiers may be taken from a single source, such as the client wristband. The client's room number is not to be used as a client identifier. Test(s) for Compliance Major The team uses at least two client identifiers before providing any service or procedure The team confirms the client's identity, nature, and site of the procedure immediately before the interventional procedure The team follows the organization's policies and procedures for administering medications such as contrast media, sedatives and radiopharmaceuticals. 23

27 The organization's policies and procedures include identifying who is responsible for prescribing, storing, handling, and disposing of medications; preparing medications as per manufacturer's instructions; selecting type and dose for each procedure; using dose protocols for pediatric clients; ensuring that the correct agent is selected prior to administration; verifying the color, clarity and expiration date of the agent; and treating adverse reactions or complications The team monitors clients receiving medications such as contrast media, sedatives and radiopharmaceuticals during and after the examination for adverse reactions or complications When sedatives or anesthesia is administered, the client is monitored by qualified team members during and after the examination. Qualified team members include physicians, anesthetists, or nurses The team follows the organization's policy and procedure for treating, documenting, and reporting adverse reactions. Adverse reactions are documented in the client record. Organizations are encouraged to report adverse reactions to Health Canada. Information on reporting adverse reactions can be found online at When medications such as contrast media, sedatives and radiopharmaceuticals are administered to the client, the team ensures it has immediate access to staff trained to deal with medical emergencies (e.g. CPR training), emergency cart, and oxygen equipment. An emergency cart includes emergency drugs and resuscitation equipment appropriate to the client population (e.g. pediatrics). 24

28 11.11 The team implements standard views of each anatomic area to optimize imaging and minimize exposure to radiation. In radiology, technique charts of exposure factors and appropriate collimation are used to limit exposure to the anatomic area being examined. Listing exposure factors will reliably produce diagnostic radiographs of anatomic parts of clients of different sizes to minimize the need for repeat exposures. Repeat rates are part of the routine quality control process The team uses diagnostic reference levels to optimize radiation protection of adult and pediatric clients. Client-centred Services One of the challenges faced by diagnostic imaging providers is minimizing the radiation dose to the client without compromising the image quality needed to make an accurate diagnosis. Using Diagnostic Reference Levels (DRLs) protects clients from unnecessary radiation exposure by using a dose that is as low as reasonably achievable. Health Canada has a list of recommended DRL values for a number of radiographic procedures performed on adults and children. The team may set DRLs for other procedures not presented in the list but which are being performed at the organization. DRL measurements can either be performed with a phantom specifically designed for the procedure or with clients. The recommended minimum sample size is 10 clients. For more information, refer to Health Canada Code 35: Section 3.5 on Diagnostic Reference Levels (2008) The team follows appropriate policy and procedures for each diagnostic imaging technique For interventional procedures, the team labels, handles, transports, tracks and stores samples safely and appropriately. 25

29 11.15 The team reviews diagnostic images for positioning and diagnostic quality before the client is released. The team has a process to review the quality of images and assess the necessity for repeat imaging. The team repeats diagnostic imaging examinations only when diagnostic quality is sub-optimal The team follows policies and procedures for determining whether a client is fit for release. Policies and procedures specify when a review by a radiologist is required before the client is released The team provides clients with post-procedure instructions in the event that complications arise after their release The team interprets diagnostic imaging information The team interprets elective, urgent and emergent diagnostic imaging results in a timely manner. Efficiency The organization defines what timely means based on the urgency of the request and adheres to that schedule The team evaluates whether it is meeting the timeframes set for interpreting diagnostic imaging results and makes improvements if needed. 26

30 12.3 The team informs the referring medical professionals immediately following unusual, unexpected, or urgent findings. Unusual, unexpected, or urgent findings are those that require immediate case management decisions. In addition, the team notifies the referring medical professionals if discrepancies are found between the emergency or preliminary report and the final written report The team documents the communication of results to referring medical professionals The team reports diagnostic imaging results immediately following interpretation of the images to the appropriate medical professionals The report identifies the client, the diagnostic imaging provider, the name of the referring medical professional, and includes relevant information about the procedure. Basic client identifiers include the client's name, identification number, age or date of birth, gender, contact information and history (e.g. known allergies) where applicable. Where appropriate, the report also includes the date of last menstrual period; type of contrast media used; amount of contrast or materials used; radiopharmaceutical administered; a description of other medications received; catheters and devices used; fluoro time; issues with the request for the diagnostic imaging examination; reasons for additional views or examinations; whether a preliminary verbal or written interpretation has been given; and comparative information with previous diagnostic imaging examinations if any The report describes the procedure using anatomical and precise diagnostic terminology. 27

31 13.3 The report is reviewed for accuracy, authorized by written or electronic signature, and includes the name of the radiologist who dictated the report. If applicable, the report also includes the name of the resident physician or fellow The team stores diagnostic images and reports together in a clearly labeled master envelope, electronically, or a combination of both. Whether the diagnostic images and reports are stored in master envelopes or electronically, this information is labeled with the client name, client identification number, and a second client identifier such as health care number or date of birth, and the organization name or site identifier. The master envelope or electronic copy is retrievable. 28

32 KEEPING RECORDS ACCURATE, UP-TO-DATE, AND SECURE 14.0 The team maintains accurate and specific medical records and diagnostic images The medical record includes a written or electronic requisition form for the diagnostic imaging service conducted The requisition form identifies the client, diagnostic imaging provider, the name of the referring medical professional, and information about the procedure. Basic client identifiers include the client's name, identification number, age or date of birth, gender, contact information and history (e.g. known allergies) where applicable. Information about the procedure includes the date of request; date received; date of examination; number of images taken; and medications administered including type of contrast used, amount of contrast and/or materials used, fluoro time, and radiopharmaceuticals The team's diagnostic imaging provider records their initials, name or code (written or electronic) to signify their involvement with the diagnostic imaging procedure The diagnostic image includes the client's first and last name, a second client identifier, the organization's name, and the time and date of the examination. 29

33 14.5 The team stores securely a copy of the diagnostic image as the permanent record The permanent record can be retrieved for updates if required. This ensures that pertinent findings may be recorded, used for comparison with further examinations, and third party diagnostic imaging teams are able to confirm the diagnosis from a review of the image The team uses computer or paper file systems to transmit and store medical records and diagnostic images. Efficiency 14.8 Diagnostic images and reports can be retrieved using client identification information. Efficiency The secure storage of images, reports, or medical records ensures client privacy The team follows the minimum requirements for retention of medical records consistent with provincial guidelines. Efficiency 30

34 MONITORING THE SAFETY AND QUALITY OF DIAGNOSTIC IMAGING SERVICES 15.0 The team promotes safety in the diagnostic imaging service environment The team has a safety program led by a safety officer, a safety committee, or both. The safety officer or committee is responsible for stopping activities that are deemed unsafe; reviewing all incidents; and making recommendations to prevent a recurrence of an incident. The safety officer or committee may also be responsible for reviewing the content of the organization's safety manuals and their availability; reviewing orientation, training and education programs, monitoring and evaluating the functions of the organization as they relate to safety; and reviewing and signing off on all documented incidents and recommendations The team has a safety manual adapted for diagnostic imaging services. The safety manual includes requirements specific to diagnostic imaging services such as client and staff safety; equipment safety; radiation safety; magnetic safety; fire safety; electrical safety; compressed gases; chemicals, solutions, and radioactive material; waste management and disposal; and infection control The team has policies and procedures to deal with medical emergencies. Examples of medical emergencies for diagnostic imaging services include adverse reactions to contrast media The team prepares for medical emergencies by participating in simulation exercises. 31

35 15.5 The team has a process to receive, document and follow-up on medical alerts and safety notifications issued by Health Canada and provincial regulatory bodies REQUIRED ORGANIZATIONAL PRACTICE: The team implements and evaluates a falls prevention strategy to minimize client injury from falls. Falls may lead to client injury, increased health care costs, and possibly claims of clinical negligence. Falls prevention programs may include but are not limited to staff training, risk assessments, balance and strength training, vision care, medication reviews, physical environment reviews, behavioural assessments, and bed exit alarms. Possible measures to evaluate a falls prevention strategy may include tracking the percentage of clients receiving a risk assessment, falls rates, causes of injury, and balancing measures such as restraint use. Conducting post-fall debriefings may also assist to identify safety gaps, and to prevent the recurrence of falls.. In Canada, Safer Healthcare Now! has identified falls prevention as a safety priority. Reducing falls and fall injuries can increase quality of life for clients and reduce costs associated with serious injury from falls. Test(s) for Compliance Major The team implements a falls prevention strategy. Major The strategy identifies the populations at risk for falls. Major The strategy addresses the specific needs of the populations at risk for falls. Minor The team establishes measures to evaluate the falls prevention strategy on an ongoing basis. Minor The team uses the evaluation information to make improvements to its falls prevention strategy. 32

36 15.7 REQUIRED ORGANIZATIONAL PRACTICE: The team informs and educates clients and families in writing and verbally about the client and family's role in promoting safety. Clients and families play an important role in preventing adverse events. Their questions and comments are often a good source of information about potential risks, errors, or safety issues. Clients and families are able to fulfill this role when they are included and actively involved in the process of care. Many organizations have developed materials that relate to client safety-related issues and provide guidance and direction for questions and topics to address during care. Examples of client safety educational materials include the Manitoba Institute of Patient 's It's Safe to Ask, and the Ontario Hospital Association's Your Healthcare Be Involved". Test(s) for Compliance Major The team develops written and verbal information for clients and families about their role in promoting safety. Major The team provides written and verbal information to clients and families about their role in promoting safety The team identifies high-risk activities and implements verification processes to mitigate risk. To identify high-risk activities the team may review their services and use this information to develop and implement checking systems to reduce the risk of harm to clients. Across the care continuum, systems will vary depending on services. Examples may include but are not limited to: Repeat back or read back processes for diagnostics or verbal orders Checking systems for water temperature for client bathing Standardized tracking sheets for clients with complex medication management needs Automated alert systems for communication of critical test results Computer-generated reminders for follow-up testing in high-risk patients Two person verification process for blood transfusions Independent double checks for the dispensing/administration of high-risk medications Medication bar coding systems for drug dispensing, labeling, and administration Decision support software for order entry and/or drug interaction checking monitoring systems for service providers in community-based organizations, or for clients in high-risk environments Standardized protocols for the monitoring of fetal heart rate during medical induction/augmentation of labour, or in high-risk deliveries Systems for monitoring of vaccine fridge temperatures Standardized protocols for the use of restraints Standardized screening processes for allergies to contrast media. 33

37 15.9 The team identifies, reports, records, and monitors in a timely way sentinel events, near misses, and adverse events. The organization defines what timely means and adheres to that schedule. This includes investigating all incidents, e.g. sentinel events, near misses, and adverse events, taking action to prevent the same situation from recurring, monitoring incidents, and using lessons learned to make improvements. The team is responsible for implementing the organization's process. In addition, information about sentinel events, near misses and adverse events is tracked for diagnostic imaging services specifically and reported in a manner that is consistent with others across the organization so that the information may be summarized at the organization level The team follows the organization's policy and process to disclose adverse events to clients and families The team has a quality control program for its diagnostic imaging services The team maintains a schedule of quality control procedures The team records results of quality control procedures, problems identified, and corrective action taken The team conducts and reports on repeat/reject analysis monthly, as part of its quality control program. 34

38 Repeat/reject analysis is used to determine the cause of non-diagnostic film or digital images and to indicate required improvements The team documents all repeat/reject analysis including corrective action taken The team retains repeat/reject records for the period set by the organization's policy. The organization's policy on record retention should be in line with applicable provincial and federal regulations The team collects and uses indicator data to guide its quality improvement initiatives. As of January 01, 2015, this criterion comes into effect and will be assessed during on-site surveys. Client-centred Services 17.1 The team collects information and feedback from clients, families, staff, service providers, organization leaders, and other organizations about the quality of its services to guide its quality improvement initiatives. The team gathers information and feedback in a consistent manner from its key stakeholders about the quality of its services. Feedback, in the form of client and family satisfaction or experience data, complaints, indicators, outcomes, scorecards, incident analysis information and financial reports, may be gathered by a variety of methods, including surveys, focus groups, interviews, meetings, or records of complaints. As of January 01, 2015, this criterion comes into effect and will be assessed during on-site surveys The team uses the information and feedback it has gathered to identify opportunities for quality improvement initiatives. The team uses feedback as well as other forms of information, and observation and experience, to identify and prioritize areas for quality improvement initiatives. This is done using a standardized process based on criteria such as client-reported outcomes, risk, volume, or cost. 35

39 As of January 01, 2015, this criterion comes into effect and will be assessed during on-site surveys The team identifies measurable objectives for its quality improvement initiatives and specifies the timeframe in which they will be reached. Quality improvement objectives define what the team is trying to achieve, and by when. Appropriate quality improvement objectives have targets that exceed current performance. Quality improvement objectives are typically short term and are aligned with longer-term strategic priorities or patient safety areas. The timeframe will vary based on the nature of the area for improvement. The SMART acronym is a useful tool for setting meaningful objectives, in that they should be Specific, Measurable, Achievable, Realistic, and Time-bound. The United States Centers for Disease Control and Prevention offers a guide to writing SMART objectives. As of January 01, 2015, this criterion comes into effect and will be assessed during on-site surveys The team identifies the indicator(s) that will be used to monitor progress for each quality improvement objective. The team uses indicators to monitor whether the activities resulted in change and if the change is an improvement. Primarily, indicators are selected based on their relevance and ability to accurately monitor progress. When there are multiple potential indicators, the team uses criteria to select indicators, such as scientific validity and feasibility. If the team has difficulty selecting indicators, it may mean the quality improvement objective needs further clarification. As of January 01, 2015, this criterion comes into effect and will be assessed during on-site surveys The team collects, analyzes, and interprets data on the appropriateness of examinations, the accuracy of the interpretations, and the incidence of complications and adverse events. For example, in teleradiology and other diagnostic tests, data is collected on the appropriateness and quality of transmitted data. As of January 01, 2015, this criterion comes into effect and will be assessed during on-site surveys The team reviews its diagnostic reference levels at least annually as part of its quality improvement program. 36